PITTSBURGH, PA — Insomnia and other sleep disorders, which affect one out of every two servicemembers or veterans who have been involved in recent military operations, complicate co-morbid conditions and can be difficult to manage.

A new report, however, offers reassurance to clinicians that tools exist to treat the insomnia and sleep disruption. Adam Bramoweth, PhD, of the VA’s Pittsburgh Healthcare System, and Anne Germain, MD, PhD, of the University of Pittsburgh School of Medicine reviewed research on deployment-related insomnia among military personnel and veterans since 2010.

Their conclusions were published recently in the journal Current Psychiatry Reports.1

“Yes, insomnia is a solvable/treatable problem,” Bramoweth told U.S. Medicine. “Well-established, evidence-based cognitive-behavioral treatments can help significantly reduce insomnia severity and in many cases lead to a cessation of symptoms. It also teaches a skill that can be reapplied as needed since insomnia often re-emerges across the lifespan for numerous reasons.”

Bramoweth said cognitive-behavioral therapy for insomnia (CBTI) is the first-choice treatment for insomnia, ahead of sedative-hypnotic medications, based on guidelines from groups such as the National Institutes of Health and the British Association of Psychopharmacology.

“CBTI helps to re-establish a structured and consistent sleep/wake schedule and helps to reduce the amount of time it takes to fall asleep, reduce time awake at night and increase subjective quality of sleep,” he pointed out. “CBTI is relatively brief, usually four to six in-person sessions. Newer, evidence-based adaptations have been developed, such as Brief Behavioral Treatment for Insomnia, which applies the same evidence-based methods but is delivered in two in-person sessions and two phone-based sessions.”

The study acknowledges the nationwide dissemination of CBTI training with the VA, with the goal of training 1,000 clinicians in the process.

“This represents a significant effort to bridge the gap between veterans in need of services and providers available,” the authors write. “However, additional treatment efforts still are needed for veterans not eligible for VA care, active duty servicemembers, and families of military personnel.”

The review discusses programs available, but programs such as AfterDeployment.org and the VA CBTI Coach mobile application, which can be used as self-management tools or in conjunction with treatment with a clinician. It also mentions that alternative therapies, such as cranial electrical stimulation, are being tested, although a recent study showed no change in sleep for veterans compared to a sham device.

Brief treatments composed of one in-person session and three follow-up telephone calls also have shown promise, the authors wrote.

The study noted that insomnia is reported by up to 54% of the two million men and women who have served in various American combat efforts since Sept. 11, 2001, compared with up to 22% of civilian adults. Not only is insomnia a more frequent problem in servicemembers and veterans, but other sleep disruptions also are common.

“Many military servicemembers struggle with nightmares in addition to insomnia,” said Bramoweth, who suggested that Imagery Rehearsal Therapy (IRT) has shown some success in treating combined insomnia and nightmare issues.

IRT is an evidence-based cognitive-behavioral treatment focused on the alteration and reduction of nightmares, he added.

Unique Factors

The article suggested a variety of causes leading to chronic insomnia, some of them unique to or more prevalent in the military.

Among those, according to Bramoweth, are “factors such as adverse childhood events and patterns of sleep that may have been developed during military service but prior to deployment.”

U.S. Army paratroopers with the 82nd Airborne Division’s 1st Brigade Combat Team relax between patrols at Joint Security Station Hasan in 2012 in southern Ghazni Province, Afghanistan. Many of the paratroopers sleep under the stars in shallow bunkers referred to sometimes as “Ranger graves.” Photo by Sgt. Jonathan Shaw

In addition, he said, “the deployment experience itself, especially to a combat zone, can be the precipitating factor in the development of insomnia. Many soldiers are also subject to shift work schedules and rotating schedules. This makes it difficult to establish healthy sleep/wake patterns. This can occur when a soldier is out in the field or even stationed at a base and not directly exposed to combat.”

Hypervigilance also is an issue “which many soldiers experience on deployment, especially if stationed at a forward operating base that can be exposed to things like rocket attacks or a soldier who directly involved in combat,” he added.

While necessary and protective in a war zone, Bramoweth pointed out, hypervigilance “makes falling asleep — a vulnerable state — very difficult.”

Other factors include:

Lack of physical or mental comfort during deployment. Temperature, noise, comfort of mattress/bunk can all play a role in the ability to fall asleep and stay asleep;

The high levels of energy drink consumption among military servicemembers;

Development of co-morbid conditions such as post-traumatic stress disorder (PTSD), depression, adjustment disorders, anxiety which can lead to insomnia, which in turn increases the risk of developing psychiatric disorders and alcohol/substance use disorders.

Once those patterns begin, Bramoweth said, “Insomnia most often becomes chronic due to perpetuating factors and behaviors.”

Getting at the root of the problem by improving sleep patterns during deployment can be extremely difficult, however.

“One of the foundations of treatment is keeping a consistent schedule, which is difficult (and near impossible for some servicemembers) to accomplish while deployed,” he explained. “But some efforts can be made even on deployment, such as trying to keep a consistent sleep/wake schedule when the opportunity allows and avoiding high intake of caffeinated drinks. However, most treatment occurs and is most likely to be successful post-deployment.”

The researchers underscored the importance of additional investigations to reveal underlying psychological, socio-environmental, physiological and neural reasons for chronic insomnia among military personnel. Early identification and timely interventions also are important to reduce the impact of deployment on sleep, to improve recovery from insomnia and to ultimately help prevent the onset of related psychiatric conditions, they add.

“Training providers to be knowledgeable about insomnia and behavioral treatment options is a vital component to the treatment of chronic insomnia and managing its impact on other disorders,” according to Bramoweth and Germain. “In addition to research and clinical efforts specifically for servicemembers and veterans, research and clinical efforts directed at military family members are also important components in providing the care needed and promoting health and recovery among servicemembers and their families.”